Nursing Assessment Chest Pain

Nursing Assessment Chest Pain


History :

  1. What are the complaints? (specific words, location, severity)
  2. Are there other signs or symptoms? (lightheaded, dizzy, nausea, palpitations, indigestion, breathless)
  3. What was the resident doing when it started ?
  4. What is the contributing medical history? (Angina, CAD, MI, GI problem, respiratory illness, HTN, chest wall syndrome, anxiety) ?
  5. Are there other new status changes? (confusion, lethargy, agitation, slumping, flaccid limb, drooling)
  6. What cardiac meds are ordered? Any recent med changes? Is the resident on Coumadin and/or Aspirin ?

Physical :
  1. What are the vital signs? (apical pulse, any new rhythm change)
  2. If diabetic, what is the Accucheck reading ?
  3. What is the color & temperature of the skin? (dry, warm, cool, clammy, diaphoretic, pale)
  4. Are there new abnormal lung sounds? (wheezes, rales/crackles, rhonci)
  5. Is the abdomen tender on palpation? Bowel sounds? Last BM? DO NOT check for impaction !
  6. Any increase in edema (periorbital, hands, lower extremities) ?

Response :
  1. For known cardiac condition implement PRN Nitroglycerin order, Put to bed; apply oxygen at 2L via NC.
  2. If new onset chest pain put to bed, apply oxygen at 2L via NC and place emergency call.
Source : http://www.ltcpractice.com